Another doctor wrote a note next to my name. I wasn't supposed to see it.
It came to me sideways. My business-development manager had a screenshot on her phone — taken from a referrer's phone, the kind of person who quietly logs which patient gets sent to which hospital across the city. A ledger of where the difficult ones go. She turned the screen toward me almost by accident. And there, against my name, in someone else's handwriting, were four words: difficult cases, complex cases — Dr. Biswajit.
I sat with that for a long moment. Not because it was flattering, though it was. Because it was a description of me written by someone who had never asked my opinion of myself. There are surgeons in Muscat far better than I am — more gifted hands, longer training, cleaner pedigrees. But the note didn't say that. It said I was the one you sent the cases nobody else wanted to touch. It was not my word for myself. It was someone else's. And a lot of patients, it turns out, arrive at my door on the back of those four words.
You already know this feeling from the other side. You've watched a senior consultant's name get spoken in a referral while yours sits unmentioned in the same department. You've done the harder operation and watched the softer reputation collect the credit. You've wondered, at the end of a 36-hour stretch, what it would take for the city to write your name beside anything at all. I wondered it too, for years. So let me be honest: I did not set out to be that surgeon. There was no plan, no clever niche I chose on a Sunday afternoon. Here is how it actually happened — and why I now think it is the only thing that reliably builds a practice worth having.
It started where most of my good lessons start. At the bottom.
I trained and first practised in Chennai. High volume, busy theatres, no shortage of patients in the city — and almost none of them mine. The mechanism that gathered patients there was rigged in ways nobody says out loud. Surgeons paid subscriptions to an app to climb the recommended list. Others ran on spurious editorials, or held little conferences for journalists so they'd get written up the following week. Patients were drawn to centres of gravity, to the names that already had names. Nobody was willing to try one person. I was outside the loop, and back then I didn't even have the language to understand why my practice would not catch.
Then I moved to Muscat, and I rebooted from zero.
That sounds like a loss. It was the permission. I was restarting right from zero, and that made all the difference, because I had nothing to lose and I had lots of time. I was itching to do. When you have a reputation, every case is a thing you can damage. When you have nothing, every case is a thing you can build. The empty diary that should have frightened me was the most freeing thing that ever happened to my career.
My first case in the new country walked in almost immediately: a bilateral knee replacement on a patient who weighed 140 kilograms. High BMI, high risk, the kind of patient an anaesthetist looks at and starts reaching for reasons. Mine did exactly that — a cardiac reference, a physician reference, do it under epidural and hope. I sat the patient down and laid out every risk, the way I'd want it laid out for my own father. And he looked at me and said, "Doctor, I'm in your hands. I trust you." We went ahead. It went well. Two months later he had lost 40 kilograms, walked into review at around 100, and insisted on photographs with me — both of us grinning like fools. A risky patient had turned out well, and something in me shifted. I can do cases here.
That is the rung the whole thing is built on. Not the operation. The realisation that a hard case, taken on and seen through, is worth ten easy ones you turned away. After that I took a tendon injury several hospitals had passed around, each referring it onward like a parcel nobody wanted to sign for. I did it. It worked. Then a chef came in who couldn't extend his thumb — a ruptured thumb tendon that needed a transfer I had never performed in my life. I read up, I took the risk. It worked. You take tiny risks and build on them. You don't jump to a complicated case immediately — you go step by step. As the majority turn out well, you get motivated, and your patients go and speak for you. That is the entire engine, and at this point it looks clean and upward and almost easy.
It was not.
Here is the part most surgeons would edit out of the story. I am leaving it in, because without it the rest is just a brag, and a brag has never helped anyone at 2 AM.
The cases did not all turn out the way I wanted. I had a fracture of the neck of the humerus — a straightforward case, the kind you do without losing sleep — and it got infected. So I went back in. Repeated wound dressings, debridement, again, again, the slow grinding work of pulling a patient out of a hole you did not expect to dig. The wound healed eventually. The fracture healed. But for weeks I carried it.
I did a knee replacement on a woman who, looking back, did not have much arthritis to begin with. I thought a knee replacement was a simple thing — just get it done. That was not the case. Her recovery was painful, and she told me so, later, in plain words. That one I think about differently — not as a complication I rescued, but as a case I perhaps should not have done. There was a wrist, too, operated four or five times in pursuit of a perfect X-ray — but I've told that story already, in another letter about knowing when to stop. The point is the pattern, not the parade.